Provider First Line Business Practice Location Address:
1957 E 17TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-6429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-1100
Provider Business Practice Location Address Fax Number:
208-523-1317
Provider Enumeration Date:
07/10/2019